Get Help ‘Creating a Healthy Lifestyle’ March 14 at Gifford

Free health fair and diabetes expo focuses on chronic illness

Gifford chefs Ed Striebe and Steve Morgan

Gifford chefs Ed Striebe, left, and Steve Morgan present at a past Diabetes Education Expo. The annual, free event is expanded this year to all with chronic illnesses and includes a health fair as well as presentations, including a cooking demonstration by Morgan.

Gifford Medical Center will hold a free Health Fair and Diabetes Education Expo on Friday, March 14 from 10 a.m. to 2 p.m. in the Randolph hospital’s Conference Center and visitors’ entrance.

The fair, redesigned from past years, is open to anyone with a chronic condition, not just those with diabetes. It does not require registration, and puts a strong emphasis on “Creating a Healthy Lifestyle” – the fair’s theme.

Gifford has held a Diabetes Education Expo for eight prior years. While the diabetes epidemic remains, organizers from Gifford’s Blueprint for Health team decided to expand the event this year to other conditions because so much of what is being discussed is applicable, explained Jennifer Stratton, Gifford certified diabetes educator.

“Most people who have chronic conditions have something in common,” Stratton said. “I also wanted to open it up to those with pre-diabetes to help prevent diabetes from actually happening.”

The day includes vendor booths and a health fair open throughout the 10 a.m. to 2 p.m. event. Vendor booths are located in the hospital’s visitors’ entrance south of the hospital near the Gift Shop. Vendors this year are local community resource agencies and organizations talking about services and help available locally.

Health fair booths are in one of the hospital’s conference rooms and include blood pressure checks, foot checks, glucose monitoring, goal-setting guidance and guidance on healthy lifestyle choices, physical therapy exercises, tobacco cessation help, diabetes education, information on support groups, and more. The booths are operated by experts from Gifford as well as local dentist Dr. John Westbook and local optometrist Dr. Dean Barelow.

Special presentations will also be offered in a second conference room, including a 10-10:45 a.m. talk by Stratton on “Advances in Diabetes Management;” an 11-11:30 a.m. talk on “Using Herbs to Complement Your Diabetes Wellness Plan” by Sylvia Gaboriault, a registered dietitian and certified diabetes educator; and a 1-1:30 p.m. cooking demonstration on “Sugar ‘Less’ Baking” with Gifford chef Steve Morgan.

Participants may drop in or stay all day. A couple of raffle drawings will be offered and the hospitals’ cafeteria will be open for those wishing to buy lunch.

Learn more by calling Gifford’s Blueprint team at (802) 728-7710. Gifford Medical Center is located at 44 S. Main St. (Route 12) in Randolph. Drive past the hospital, south on Route 12, and take the entrance just after the medical center to access the visitors’ entrance. The Conference Center is marked with a green awning. For handicapped accessibility, go in the main entrance marked “Registration” and take the elevator to the first floor.

Responding to Community Needs

Vermont Blueprint for Health

Gifford’s Blueprint for Health Team has expanded to include additional mental health and addiction counselors offering one-on-one care at all Gifford primary care locations. In this file photo, from left, care coordinator Keith Marino, Health Connections (financial assistance) case worker Michele Packard and certified diabetes educator Jennifer Stratton discuss a patient at the Bethel Health Center.

In 2012 as part of the federal Patient Protection and Affordable Care Act, Gifford Medical Center completed a Community Needs Assessment.

Less than two years later, the Randolph-based medical center has already made huge strides addressing many of the needs found in that study.

In a survey of Town Meeting attendees in nine communities in 2012 plus feedback from other groups, community members’ described their priorities for a healthy community, perceived health problems and risky behaviors in the community, and their health needs or lacking services.

Among factors for a healthy community were good jobs and a healthy economy, access to health care, good schools, and healthy behaviors and lifestyles. Top health problems listed by survey respondents included addiction, obesity, and unhealthy lifestyle choices. Top health needs, or services community members have tried unsuccessfully to access, within the community were assisted living and nursing home care, alcohol and drug counseling, and dental care.

Today, Gifford is preparing to break ground in the spring on a senior living community in Randolph Center that will, over time, provide a full spectrum of housing options including the relocation of its award-winning nursing home and newly created assisted and independent living. Gifford has earned the coveted Federally Qualified Health Center (FQHC) designation, making it one of only three hospitals in the country to be both a Critical Access Hospital and an FQHC. This means expanded access to care, including dental and mental health care. And the medical center’s Vermont Blueprint for Health Team has greatly expanded over the past year to include more mental health and addiction counselors, providing services at all Gifford primary care locations.

chronic illness support group

Among Gifford’s free community services is a chronic illness support group. Here Gifford pharmacist Jane McConnell provides medication advice to past participants.

“Each of these major initiatives, which have taken substantial work, targets an identified community health need. Meeting these needs and addressing the community’s feedback defines the future of Gifford and its expanding role,” says Ashley Lincoln, director of development and public relations at Gifford.

The Community Needs Assessment process is required every three years, but Gifford’s efforts are ongoing. The medical center continually provides community outreach initiatives to meet care needs, many of which are offered for free. These include classes, support groups, and health fairs. Additionally, many initiatives support local economic health, including a buy local approach.

The medical center also continues community outreach daily through a boots-on-the-ground approach that has Blueprint Community Health Team working directly with individuals and community organizations to address health and socioeconomic needs, particularly for the chronically ill.

“The Blueprint for Health is a statewide initiative. Gifford has placed extra focus on meeting community members’ needs so they can successfully manage their health,” says Blueprint Project Manager LaRae Francis. “This approach means not waiting months or years for needs to be determined, but matching resources and needs today to create an ongoing healthier community for all.”

A grant from through the Vermont Department of Health helped support the costs of the 2012 report. The full report is available on Gifford’s website in the “About Us” section under Community Reports.

A Message from the Medical Directors

The following was published in our 2012 Annual Report.

medical directorsReflections on the past remind us of our roots and of how health care has changed in the past decades. Chief among those is the increasing role mid-level providers, such as nurse-midwives, nurse practitioners, and physician assistants, play in health care. Today, we have diverse physician-led health care teams in every area of medicine to encourage and support wellness.

Mid-level providers are extremely instrumental at birth, during hospital stays, in the primary care setting, specialty clinics, and even for our surgical patients. This team approach to care improves provider access and quality of care.

At Gifford, we are transitioning with great success to a team-based approach and are taking steps to ensure continued access to high-quality health care.

In 2012, some of those steps included new radiology services and technology, such as more interventional offerings, an upgraded 64-slice CT scanner, and a fluoroscopy room.

The midwifery team has expanded to the Twin River Health Center in White River Junction. Gifford’s approach to obstetrics and gynecology has grown to include more complicated cases.

The Blueprint Community Health Team has expanded and behavioral health is increasingly a part of Gifford’s offerings. Thanks to a generous gift from the Auxiliary, new CarePoint EKG transmission technology is available between our Emergency Department and ambulance services to identify heart attacks in the field and determine the best and fastest course of treatment.

Urology offerings have also grown and the Cancer Committee continues to expand. The Sharon Health Center sports medicine team has welcomed a nurse practitioner and second chiropractor.

These improvements are examples of the changes and quality upgrades we, as part of the health care team, can affect in an institution of the size and mindset of Gifford for the betterment of the community. Meld these improvements with Gifford’s foundation of patient care and advocacy, and we have a formula for success for decades to come.

Ovleto Ciccarelli, MD, Surgery Division
Martin Johns, MD, Hospital Division
Joshua Plavin, MD, MPH, Medicine Division

Get Help Signing Up for an Insurance Plan from ‘Navigators’

Vermont Health Connect

Beginning Jan. 1, federal law requires all Americans to have health insurance or face a tax penalty. Gifford has specially-trained staff called “navigators” available to help you sign-up for a health plan.

This information appeared in our
Fall 2013 Update Community Newsletter.

Beginning on Jan. 1, federal law requires all Americans to have health insurance or face a tax penalty.

In the Green Mountain State, Vermont Health Connect is the new online marketplace where individuals, families and businesses with 50 or fewer employees can shop for, compare and purchase insurance plans.

Open enrollment for these plans began this October. Vermonters can determine their eligibility and enroll online. For those without computer access or needing in-person support, Gifford has resources to help.

Across the state, “navigators” have been trained and taken rigorous exams to provide one-on-one assistance with the Vermont Health Connect marketplace.

Gifford has three navigators through its Health Connections office, a part of the Vermont Coalition of Clinics for the Uninsured, as well as the medical center’s Blueprint for Health team.

If you’re:

  • A Vermonter without health insurance,
  • A Vermonter who currently purchases insurance yourself,
  • A Vermonter with Medicaid or Dr. Dynasaur,
  • A Vermonter with Catamount or the Vermont Health Access Program,
  • A Vermonter with “unaffordable” coverage provided by your employer, or
  • A small business with 50 or fewer people

and you need help understanding the exchange, get help by calling Gifford Health Connections at 728-2323.

Individuals who are fully enrolled by Dec. 16 will have health coverage starting Jan. 1.

Under Vermont Health Connect, an employer-sponsored plan is considered “unaffordable” if your premium for yourself is more than 9.5 percent of your household income. To learn more, call (855) 899-9600 or visit www.healthconnect.vermont.gov.

A Message from the Medical Staff President

The following was featured in our 2012 Annual Report.

Marcus Coxon

Marcus Coxon

Our effectiveness as a medical home has grown this year with the expansion of health care teams and our collaboration with the Vermont Blueprint for Health. But at the heart of these teams are Gifford’s long-established primary care practices. In each of our health team locations, we have providers and support staff whose relationships with the community run deep.

Take Starr Strong, for example. For 19 years, Starr has committed herself to the people of Chelsea – first under the mentorship of Dr. Brewster Martin and now as a mentor in her own right.

With humility and compassion, family physician Dr. Ken Borie has cared for the people of Randolph for 32 years. The humanity he brings to medicine is an example for all, including the many medical students who he guides through the family medicine portion of their clinical studies.

And Dr. Lou DiNicola, a local pediatrician for 36 years, has been among the foremost leaders in this state when it comes to children, advocating at every turn for their health, safety, and welfare.

Those of us enjoying long-standing relationships with Gifford and with our central Vermont community consider ourselves fortunate to know and work with these practitioners and their support teams. Such stability, and depth, builds our medical homes into more effective tools for helping our patients.

~ Marcus Coxon
Medical Staff President & family physician

For the Love of Patients, Families, and the Community – Dr. Lou DiNicola

Dr. Lou DiNicolaBorn in New Jersey, Dr. Lou DiNicola moved to Randolph in June of 1976 to become a local pediatrician. Passing up job offers in much larger areas then and since, he chose to stay in Randolph because he’s been able to able to practice medicine as he always envisioned. He has been able to affect change on a state level; create unique, trend-setting models of health care; and demonstrate his love of the community through his work.

Married to his wife Joann for 43 years, the couple has two grown children, two grandchildren, and a third on the way. Dr. DiNicola is an outdoor enthusiast, enjoying hiking, snowshoeing, walking, and gardening. He’s also a photographer and works with his artist wife, framing her paintings. 

Dr. DiNicola has spent his entire career in Randolph while also working in Rochester from 1977-1992 with internal medicine physicians Drs. Mark Jewett and Milt Fowler. 

Below is his story as told in his own words, as featured in our 2012 Annual Report.

Thirty-six years ago I was fresh out of residency and looking for job opportunities when I saw an ad in a magazine for a pediatrician in rural Vermont. Vermont was where I wanted to work, so I sent in my curriculum vitae, the medical equivalent of a resume, but never heard a word back. I called but the response was less than enthusiastic. I was basically told “thanks, but no thanks.”

I had three job offers in Pittsburgh and was literally sitting down to take a job at Children’s Hospital of Pittsburgh where I’d just completed my internship and residency when my pager went off. It was Gifford President Phil Levesque’s secretary, wondering if I could come up in a couple of weeks for an interview. “I’ll come this weekend, or I’m not coming at all” was my response. The secretary covered the phone, relaying my message to Phil. “Hell, let him come” was his reply.

Needless to say, I came, and stayed.

More than three decades later I hope I have made a positive impact on the community and my patients, and know they have made a remarkable impact on me – teaching me how to communicate care, respect, and love.

It’s amazing how much you can love your patients. Also amazing is the window being a pediatrician gives you to see the love between a parent and a child. No more clearly is that demonstrated than in the unconditional love between a parent and a special needs child. More than once, parents of special needs children have amazed me and inspired me, as have the children themselves. I’ve seen parents of special needs children go on to adopt more children with special needs. Those are the moments that touch you most; those, and loss.

Dr. Lou DiNicola

Dr. DiNicola thumb wrestles with patient Troy Daniels.

There is no greater loss than the loss of a child. Throughout my career, there have been car accidents, disease, malignancies, and newborn deaths. I think of two patients I lost to cancer, both of whom I visited at their bedsides at home as they were dying. As I reflect on my career, I think of them not with tears but fondness because of the relationships I have had with their families.

At Gifford, we are small enough to have that closeness with our patients and courageous enough to get up the next day and reflect on what we did or didn’t do, what we could have done differently, and how we can improve care. This ability to affect change is one of the things that has kept me practicing – happily – in this community and state for so many years.

One of the biggest changes Gifford has been able to enact in health care is around childbirth. When I first came to Gifford, I kept hearing about this guy Thurmond Knight, a local physician who was delivering babies in people’s homes. I met Thurmond at a Medical Staff meeting. He was knitting. I asked him what it would take for him to deliver babies at the hospital. He answered “a Birthing Center”. We opened the Birthing Center (the first in the state of Vermont) 35 years ago in 1977.

I’ve also been fortunate to be part of and help form organizations that were decades ahead of their time, in many ways laying the foundation for today’s medical home and Vermont Blueprint for Health models as well as utilizing computers for communication at the advent of the computer revolution. Additionally, Vermont has provided me with the opportunity to work on important legislation, such as child abuse laws, outlawing corporal punishment in schools, mandatory kindergarten, and the recent immunization law. These opportunities along with the privilege of making a difference in kids’ and families’ lives keep me going.

One of the things I find incredibly rewarding is living and working in the same town. I don’t mind if I run into someone downtown and they ask me a question. And I feel it’s so important that we recognize and talk to kids. One way I have been able to successfully converse and care for kids for so long is through humor. I try to infuse that in my appointments with children and often am treated – sometimes at unexpected moments – to humor in return.

One such humorous moment came from a 5-year-old. I try to end all my appointments by asking if patients have any questions for me. This 5-year-old’s question: “Why do frogs jump so high?” Should I ever write a book, I think this will be the title.

~ Lou DiNicola, M.D.
Gifford pediatrician

Dr. Lou DiNicola

Above left – Dr. DiNicola in 1979. Above right – Dr. DiNicola with Kim Daniels of Berlin and her adopted son Troy. Troy along with his siblings, Maggie, Ben, and Alex, were patients of Dr. DiNicola’s for years. Dr. DiNicola credits Kim, who had a special needs child and then adopted two more, with showing him the true meaning of love and parenting. Troy credits Dr. DiNicola with seeing him as a person.

Year in Review – Part 2

Our 2012 Annual Report included a month-by-month “Year in Review” section. Here is the second quarter excerpt.

APRIL

Blueprint teamTo support patient needs, the Blueprint team grows to include a behavioral health specialist (social worker) and a second care coordinator.

Gynecologist Dr. Ellamarie Russo-DeMara of the Bethel and Twin River health centers leads a free women’s health talk at the Montshire Museum on menopause and genetic testing for breast and ovarian cancers.

Gov. Peter Shumlin visits the Menig Extended Care Facility to offer thanks to the state’s top nursing home, calling it a “tribute to the community”. “We’re proud of you. Thank you from the bottom of our hearts,” the governor said to residents, families, and staff members. The governor’s visit came in the wake of the U.S. News Report “2012 Honor Roll” listing.

Gov. Peter ShumlinJoining Gov. Shumlin are Vermont Disabilities, Aging and Independent Living Commissioner Dr. Susan Wehry, Vermont Health Care Association Executive Director Laura Pelosi, Division of Licensing and Protection Director Suzanne Leavitt, and Assistant Director Fran Keeler.

Gifford provides free assistance with advance directives in conjunction with National Healthcare Decisions Day.

Gifford’s more than 200 volunteers are honored with a luncheon served by hospital managers, prize awards, musical performances, and more.

Dr. Sandy Craig joins the hospitalist team, having previously practiced at The Health Center in Plainfield for many years.

March of DimesEmployees raise $455 for the March of Dimes by donning “Blue Jeans for Babies”. At the same time, the Vermont Chapter of the March of Dimes recognizes Gifford with a Leadership Legacy award for its commitment to prenatal, birth, and newborn care, and its support of the non-profit organization working to prevent birth defects, premature births, and infant mortality.

Long-time pediatrician Dr. Lou DiNicola receives a national award for his work around childhood immunizations.

Dr. DiNicola is recognized by the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases and the CDC Foundation as the first ever “CDC Childhood Immunization Champion” for the state of Vermont.

MAY

Ob/gyn Dr. Anne Galante joins the women’s health team full-time. She had worked as a Menig celebrationlocum tenens, or part-time contracted, provider at Gifford since 2009.

Menig residents celebrate a “Day of Play” with representatives of the Vermont Department of Disabilities, Aging and Independent Living. The day celebrated Older American’s Month and included a scavenger hunt.

JUNE

The Robin’s Nest Child Enrichment Center holds its annual preschool graduation, complete with caps and gowns.

Gifford and Valley Rescue Squad Inc. move forward with the formation of a new non-profit aimed at stabilizing ambulance costs and maintaining or improving quality through a new non-profit to be called Supporting Ambulances for Vermont Emergencies (SAVE).

A free men’s health talk by general surgeon Dr. Ovleto Ciccarelli and urologist Dr. Richard Graham address colorectal health, prostate cancer, and erectile dysfunction.

For an eighth consecutive year, the Menig Extended Care Facility receives a Nursing Home Quality Recognition from the Vermont Department of Disabilities, Aging, and Independent Living.

A free talk on Medicare insurance, why it’s important, why participating in Medicare Part B is beneficial, and what one’s choices are under Medicare Part D is offered.

The Commission on Cancer of the American College of Surgeons grants accreditation with commendation to the cancer program at Gifford. Gifford’s cancer program, which includes outpatient chemotherapy, has been accredited since 1965.

Family nurse practitioner Emily LeVan joins the Bethel Health Center.

Gifford is awarded a Hospital of Choice Award from The American Alliance of Healthcare Providers for “courteous, compassionate, and caring services for patients, family, and the community.” The ranking places Gifford among “America’s most customer-friendly hospitals”.

Year in Review – Part 1

Our 2012 Annual Report included a month-by-month “Year in Review” section. Here is the first quarter excerpt.

JANUARY

pediatrics' open houseUrologist Dr. Richard Graham and menopause practitioner Dr. Ellamarie Russo-DeMara of the Twin River Health Center offer a free talk at the Montshire Museum on urinary incontinence.

Gifford is once again awarded a grant from the Avon Breast Health Outreach Program. For the 11th year, Gifford is the only entity in Vermont to receive the $35,000 grant for breast cancer awareness education and outreach.

Pediatrics and adolescent medicine moves from the main medical center building to Dr. Chris Soares’ former space at the corner of South Main and Maple streets. Joining the practice on the first floor of the renovated, spacious Victorian home is pediatric physical, occupational, and speech therapies.

A free three-week series on heart health includes talks from cardiologist Dr. Bruce Andrus and registered dietitian Stacy Pelletier as well as a heart-healthy cooking demonstration from Gifford’s chefs.

FEBRUARY

As part of Gifford’s expanded efforts under the Vermont Blueprint for Health, a chronic illness support group – Chronic HealthShare Consortium – is launched and begins meeting monthly.

Dr. Ovleto Ciccarelli strives to bring colon health to the forefront with a free health talk, “Everyone’s Got One: A Discussion on the Colon and How to Keep It Healthy”.

Pacemaker surgeries return to Gifford after a quarter century hiatus.

The Menig Extended Care Facility is named among nation’s top 39 nursing homes by U.S. News and World Report, which released a list of “2012 Honor Roll” nursing homes. Menig was the only nursing home chosen in Vermont and neighboring New Hampshire.

MARCH

The 106th Annual Corporators Meeting is held at the medical center and features Steve Kimbell, commissioner of what was then the Vermont Department of Banking, Insurance, Securities and Health Care Administration. Leo Connolly, Fred Newhall, and Peter Nowlan are elected to the Board of Trustees.

A Vermont House of Representatives resolution recognizes “the outstanding health care services provided by Gifford Medical Center”. The resolution is in honor of Gifford’s more than 100 years of service to the Randolph area and for its many recent awards.

The Diabetes Education Expo focuses on teeth and feet and how diabetes can keep both healthy. It is the 7th annual exposition organized by the Diabetes Clinic especially for the growing diabetes population.

An open house is held for pediatrics’ new space at 40 South Main Street. Children attending enjoy face painting, balloons, snacks, tours of their new doctor’s office, bike helmet fittings, and painting tiles that have become part of the clinic’s permanent decor.

Gifford Volunteers Honored

Selfless community members give 16,524 hours to non-profit hospital

Susan O'Malley of Randolph

Susan O’Malley of Randolph

Gifford Medical Center recognized its 120 volunteers at an annual appreciation luncheon on Wednesday.

Volunteers gave 16,524 hours in 2012. That’s 2,066 eight-hour workdays or the equivalent of eight full-time employees, noted Ashley Lincoln, director of development and marketing. “That’s a pretty incredible number,” Lincoln said. “We really appreciate the smiles that you bring, your enthusiasm, and your willingness to come when you’re called.”

Arlene Conant of Randolph Center and Robin Rafuse Gurney of Randolph

Arlene Conant of Randolph Center and Robin Rafuse Gurney of Randolph

Volunteers give of their time throughout the medical center, at its clinics, at the Adult Day, through chaplaincy, as part of the Board of Trustees and through the Gifford Auxiliary at the Thrift Shop. “We have a far reaching volunteer group and I thank all of you,” said Volunteer Services Coordinator Julie Fischer to the group of about 75 in attendance.

The volunteers were treated to live music by Thom Goodwin, quality and infection prevention manager at Gifford and a

Chris Furmeister of Randolph

Chris Furmeister of Randolph

musician. Gifford’s chefs prepared a meal based on the event’s Texas barbecue theme. Gifford staff volunteering as servers donned Western attire. And door prizes from generous local businesses, including Onion Flats, Randolph Village Pizza, Blue Moon Boutique, Belmains, Bud and Bella’s Bookshop, Dandelion Acres, Central Supplies, Chef’s Market, Holiday Beauty Salon and Tozier’s, were given out.

Major salutes

Major salutes

One volunteer in particular received a standing ovation after it was announced that the hospital has nominated him for a senior service award. Major Melvin McLaughlin, 95, has been volunteering at Gifford for more than 40 years.

Lincoln read the hospital’s nomination, which describes McLaughlin’s service and hospital staff members’ regard for the long-time volunteer. “We at Gifford love Major. He is a brilliant and beautiful light in the day. As one nurse put it, ‘A day without Major is a day without sunshine.’ He is the personification of what we are as an organization – warm, compassionate, supportive, humbled and blessed to be able to care for others. Introduce a new staff member, patient or nursing home resident to Major and we have just told them everything they need to know about us. We care. We’re family. We’re here for you.”

Nap and Agnes Pietryka of Randolph

Nap and Agnes Pietryka of Randolph

The text of the full nomination is available online at www.salutetoseniorservice.com. Hospital administrators are hoping staff, volunteers and community members visit the site between April 15-30 to vote for McLaughlin, a Randolph resident since 1967.

McLaughlin, a member of the U.S. Marines for 25 years, saluted his fellow volunteers as they cheered him.

Volunteers also offered their thanks for the opportunity to give of their time at the medical center, an experience so many find extremely rewarding.

The event concluded with a presentation from LaRae Francis of Gifford’s Blueprint Community Health Team, who explained the team’s work to connect Gifford patients with needed community services and to help them better navigate the health system. The program is aimed at helping the chronically ill better manage their diseases by reducing barriers to care. The team has had 600 referrals since it began in February of 2011.

Community members wanting to access the program to receive help and learn about available community services can call (802) 728-2499. For information on volunteering at Gifford, call Fischer at (802) 728-2324.

The Vermont Blueprint for Health: Redefining Primary Care

The following is an excerpt from our 2011 Annual Report. Our 2012 Annual Report will be out soon.

Vermont Blueprint

Blueprint Care Coordinator Keith Marino meets in Gifford primary care with patient Cheryl Abbey of Randolph.

The Vermont Blueprint for Health is a state-led initiative aimed at improving care coordination, especially for the chronically ill. The goals of the initiative are to improve health, enhance the patient experience and reduce, or at least control, health care costs.

This is accomplished through what the Blueprint is calling “advanced primary care” that seamlessly coordinates a broad range of health and human services for patients and their families.

In 2011, the Vermont Blueprint for Health came to life at Gifford. Each of the medical  center’s primary care practices was recognized as a Patient-Centered Medical Home and a huge care coordination effort got under way to meet patients’ diverse needs.

The care coordination effort, which is supported in part by grant dollars, is twofold. First, Gifford formed its own small care coordination team made up of three core employees; Blueprint Care Coordinator Keith Marino, Gifford Diabetes Educator Jennifer Stratton and
Health Connections Caseworker Michele Packard. Second, a larger Community Health Team consisting of a diverse group of state and regional community housing, aging and disability agencies as well as eye care professionals, a pharmacy, insurers and more, was formed.

Vermont Blueprint

Blueprint core team members – Health Connections caseworker Michele Packard and diabetes educator Jennifer Stratton – meet weekly with Blueprint Care Coordinator Keith Marino at the Bethel Health Center to discuss individual patients and how to better serve them.

The Community Health Team meets quarterly while a care coordination team meets weekly. More importantly, referrals are bouncing back and forth between the agencies and teams ensuring patients are getting the services they need to maintain and improve their health. Keith coordinates this work, meeting directly with patients, spending time in each
of Gifford’s Patient-Centered Medical Homes, conferring with health care providers and helping patients access needed services.

Patients and community members are referred to Keith for a huge variety of reasons. They may need help managing chronic conditions, be struggling socio-economically, need mental health assistance, be disabled or elderly, have housing or transportation needs or just need help navigating the health system.

The Blueprint provides that help directly or refers them to an appropriate community agency. The help comes in the form of one-on-one meetings with Keith and outreach on his part to get the patient connected with needed resources.

“My role is to make sure patients are getting access to proper services, which enables them to self-manage their chronic condition,” Keith says.

Medicine Division Vice President Teresa Voci gives the example of a chronically ill patient who, because of financial pressures, has to choose between food and medication. Without medication, their health suffers. With the Blueprint services, their health care provider has a central resource to offer the patient for those issues that fall outside the health care setting but are barriers to care, like help with finding resources to buy food and medications.

Kim Flood of Barre is a real life example.

All three of Kim’s sons were diagnosed with asthma. The younger two, ages 4 and 1, were especially sick, including being hospitalized. Kim thought she knew the problem – mold in her Barre apartment.

Pediatric hospitalist Dr. Lou DiNicola referred Kim to the Blueprint. “Keith helped us find someone to do mold testing, help us with legal aid,” Kim says, “and he got city officials to come to the apartment. I had tried for months to get the housing inspector and building inspector to our house. I just got the runaround from everyone.”

With the mold verified and the help of legal aid, Kim settled with the landlord and in October moved into a home she bought in Barre Town on nine acres.

The kids haven’t been sick since.

Kim is one of 230 referrals Gifford’s Blueprint team has received since Keith was hired and the program got under way in February, notes Blueprint Project Coordinator LaRae Francis. Most of the referrals are from primary care providers, like Dr. Terry Cantlin of the Bethel Health Center.

“He’s been invaluable,” says Dr. Cantlin of Keith, who does the work primary care physicians simply do not have time to do in their busy practices.

Now if a patient is not taking their medication due to financial pressures, is missing needed appointments because of transportation issues or struggling with social issues – all scenarios Dr. Cantlin sees – he now has a one-stop resource for the patient.

It also prevents patients unaware of available community resources from “falling through the cracks,” says Mary Ellen Otis, executive director of the Orange County Parent Child Center in Chelsea.

That center, which provides a vast array of family services from new baby visits to parenting education, is part of the Community Health Team and refers clients to Gifford as well as gets referrals from the hospital. Under the new coordinated effort, Mary Ellen says, referrals are now far more efficient.

Maryette Withington can attest to that.

The Barnard resident has a relative with Alzheimer’s disease. Dr. Cantlin referred Maryette to Keith for help learning more about the disease. He met with her at the Bethel Health Center and connected her with the Randolph Area Senior Center and the Vermont Chapter of the Alzheimer’s Association. Within 24 hours Maryette had information in her hands about the disease that she says has changed everything in her life.

“You’re totally responsible for that person. I just needed to know what to expect.”

She will have an ongoing relationship with the association and also continues to receive help from Keith, Dr. Cantlin and her Gifford health care team. It’s help she appreciates. “I have the best health care team in the world,” she says.

Need help yourself? Call the Blueprint Care Coordinator at (802) 728-2499.